(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article, for policies issued or renewed
on or after January 1, 2012, which delivers, renews or issues a
policy of group accident and sickness insurance in this state under
the provisions of this article shall include coverage for diagnosis
and treatment of autism spectrum disorder in individuals ages
eighteen months to eighteen years. To be eligible for coverage and
benefits under this section, the individual must be diagnosed with
autism spectrum disorder at age eight or younger. The policy shall
provide coverage for treatments that are medically necessary and
ordered or prescribed by a licensed physician or licensed
psychologist and in accordance with a treatment plan developed from
a comprehensive evaluation by a certified behavior analyst for an
individual diagnosed with autism spectrum disorder.

(b) Coverage shall include, but not be limited to, applied
behavior analysis. Applied behavior analysis shall be provided or
supervised by a certified behavior analyst. The annual maximum
benefit for applied behavior analysis required by this subsection
shall be in an amount not to exceed $30,000 per individual, for
three consecutive years from the date treatment commences. At the
conclusion of the third year, coverage for applied behavior
analysis required by this subsection shall be in an amount not to
exceed $2,000 per month, until the individual reaches eighteen
years of age, as long as the treatment is medically necessary and in accordance with a treatment plan developed by a certified
behavior analyst pursuant to a comprehensive evaluation or
reevaluation of the individual. This section shall not be construed
as limiting, replacing or affecting any obligation to provide
services to an individual under the Individuals with Disabilities
Education Act, 20 U.S.C. 1400 et seq., as amended from time to time
or other publicly funded programs. Nothing in this section shall
be construed as requiring reimbursement for services provided by
public school personnel.

(c) The certified behavior analyst shall file progress reports
with the agency semiannually. In order for treatment to continue,
the insurer must receive objective evidence or a clinically
supportable statement of expectation that:

(1) The individual's condition is improving in response to
treatment; and

(2) A maximum improvement is yet to be attained; and

(3) There is an expectation that the anticipated improvement
is attainable in a reasonable and generally predictable period of
time.

(d) For purposes of this section, the term:

(1) "Applied Behavior Analysis" means the design,
implementation, and evaluation of environmental modifications using
behavioral stimuli and consequences, to produce socially
significant improvement in human behavior, including the use of
direct observation, measurement, and functional analysis of the
relationship between environment and behavior.

(2) "Autism spectrum disorder" means any pervasive developmental disorder, including autistic disorder, Asperger's
Syndrome, Rett Syndrome, childhood disintegrative disorder, or
Pervasive Development Disorder as defined in the most recent
edition of the Diagnostic and Statistical Manual of Mental
Disorders of the American Psychiatric Association.

(3) "Certified behavior analyst" means an individual who is
certified by the Behavior Analyst Certification Board or certified
by a similar nationally recognized organization.

(4) "Objective evidence" means standardized patient assessment
instruments, outcome measurements tools or measurable assessments
of functional outcome. Use of objective measures at the beginning
of treatment, during and after treatment is recommended to quantify
progress and support justifications for continued treatment. The
tools are not required, but their use will enhance the
justification for continued treatment.

(e) The provisions of this section do not apply to small
employers. For purposes of this section a small employer means any
person, firm, corporation, partnership or association actively
engaged in business in the State of West Virginia who, during the
preceding calendar year, employed an average of no more than
twenty-five eligible employees.

(f) To the extent that the application of this section for
autism spectrum disorder causes an increase of at least one percent
of actual total costs of coverage for the plan year the corporation
may apply additional cost containment measures.

(g) To the extent that the provisions of this section require
benefits that exceed the essential health benefits specified under section 1302(b) of the Patient Protection and Affordable Care Act,
Pub. L. No. 111-148, as amended, the specific benefits that exceed
the specified essential health benefits shall not be required of a
health benefit plan when the plan is offered by a corporation in
this state.
Note: WV Code updated with legislation passed through the 2016 Regular Session
The West Virginia Code Online is an unofficial copy of the annotated WV Code, provided as a convenience. It has NOT been edited for publication, and is not in any way official or authoritative.